Worst Case Scenario 3: Chest Tubes!

by Andria RN · 0 comments

in ICU,Podcast,Uncategorized

Chest tubes are not as scary as they sound. If the chest tube is already in place and there are no immediate problems, chances are your 12 hour shift is going to be ok. If not, we’ll teach you exactly what to do.

Chest tubes can be placed in a pleural space or a mediastinal space. Listen to our audio version (link above) for more detailed description of the differences between pleural and mediastinal and a refresher of lung anatomy and physiology. One patient can have 1-4 chest tubes that are often Y-connected together to decrease the number of drainage systems attached to the patient.

How do you assess the patient with a chest tube? Is the patient having respiratory distress? Listen over both lung fields- if one is absent or muffled, notify the MD and provide respiratory support. Check the chest tube dressing for drainage, outline any new drainage and notify the MD if there has been a drastic increase in drainage. Is the dressing intact? Vaseline gauze is helpful in preventing air leak around the chest tube and if this has become displaced, it’s often helpful to reapply the dressing. Is there any subcutaneous air around the chest tube site? Notify the MD if there is. This is called crepitus and could signify an air leak. Check the tubing for kinks and obstructions. Check the color of the drainage. Notify the MD if there is a change in output color (especially if the change is to bright red blood!) and also if the output has increased significantly. The output should decrease over time, not increase. Check the drainage system for an air leak in the water collection chamber. If there is an air leak, you will see bubbling in the chamber, the louder and higher the bubbling- the worse the air leak. Ideally, there will not be an air leak and you will see fluctuation in the water collected chamber that match the patient’s respirations. If it a new or worsening air leak, notify the MD! Determine whether the chest tube is ordered to -20cm H20 (artificially providing negative pressure to the patient) or to water seal.

Make sure the chest tubes are not clamped. Chest tubes should only be clamped when you are changing out a collected chamber and when the doctor has ordered clamping. You can also assess where an air leak is coming from by clamping different locations in the tubing. I would not recommend this as a new nurse.

Make sure you have two kelly clamps at the bedside for a patient with a chest tube. Make sure you have portable suction if your chest tubes are ordered to suction and you are traveling with your patient. If tubing becomes dislodged from patient, immediately call a code or get an MD there to replace the chest tube, then apply a 3 sided dressing to the site or place your hand over the site, lifting occasionally to vent, especially if patient is having respiratory distress. If tubing becomes dislodged from chest drainage system, ideally you’d clamp and reattach to a new sterile drainage system. If not possible, a glass of sterile water or the old chest tube drainage system might be your best bet.

Listen to the New Nurse Podcast on iTunes or download this episode via the above link. You can also listen live from the website.

As always, comments and feedback are greatly appreciated.

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